Provider Demographics
NPI:1083227250
Name:DAVIS, LOGAN JAY (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:JAY
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 WILFORD HALL LOOP
Mailing Address - Street 2:
Mailing Address - City:LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236
Mailing Address - Country:US
Mailing Address - Phone:210-292-5050
Mailing Address - Fax:
Practice Address - Street 1:86 MDG
Practice Address - Street 2:UNIT 3215
Practice Address - City:RAMSTEIN AB
Practice Address - State:RAMSTEIN-MIESENBACH
Practice Address - Zip Code:09094
Practice Address - Country:DE
Practice Address - Phone:063-714-7155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-27
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA100349225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist